Fatally Long Waits and Red Tape

The WasteWatcher is the staff blog of Citizens Against Government Waste (CAGW) and the Council for Citizens Against Government Waste (CCAGW). For questions, contact blog@cagw.org.

June 10, 2014 - 16:23 — CAGW Staff

At the corner of Vermont Avenue and H Street in northwest Washington, D.C., a single structure’s exterior bears a bronze plate engraved with the words “To care for him who shall have borne the battle and for his widow, and his orphan.” The building is the Department of Veterans Affairs, and the phrase, uttered by President Abraham Lincoln, is the agency’s motto. Sadly, this goal is not being met, and, disappointingly, it hasn’t been for nearly a decade.

The Veterans Health Administration (VHA), the largest integrated healthcare delivery system in the U.S., operates more than 150 medical centers, 820 community-based outpatient clinics, 300 veterans centers, 135 community living centers, and 70 mobile Vet Centers. VHA schedulers make 236,000 healthcare appointments each day and approximately 85 million appointments each year.

An April 9, 2014 House Committee on Veterans Affairs hearing described “criminal misconduct and gross mismanagement of VA resources” by utilizing “secret wait lists” that led to 40 possible wrongful deaths at the Phoenix, Arizona VA Health Care System (HCS). The exposure of this scandal and similar allegations involving other VA health care systems around the nation raised many questions regarding the VA’s management of both its veterans and the data used to provide patients with timely healthcare services.

The VHA currently uses a medical scheduling package (MSP) software program called the Veterans Health Information Systems and Technology Architecture (VistA), an integrated inpatient and outpatient electronic health record system and administrative tool that helps VA schedulers make appointments and accurately capture data. However, VistA is more than 25 years old. It neither meets current requirements nor provides the flexibility needed to address future needs. The VA started to develop an MSP replacement beginning in 2000. When the VA ended the project in 2009, it had cost more than $127 million and never became operational.

In order to measure wait times for veterans seeking treatment, the VA defines established patients, which make up 90 percent of the VA’s total outpatient appointments, as those who have received care within the previous two years, while new patients represent all others. For existing patients, wait times are calculated using the desired date of care to the date of a scheduled appointment. For new patients, the VHA calculates wait times from the date a scheduler creates an appointment.

On May 21, 2014, 42 days after the April 9 hearing, President Obama held a press conference during which he used the opportunity to tout his own accomplishments to improve the VA. He said, “We have made progress over the last five years. We have made historic investments in our veterans and we have boosted VA funding to record levels. And we have created consistency through advanced appropriations so that veteran’s organizations knew their money would be there regardless of political wrangling in Washington…making it easier for veterans who have post-traumatic stress and mental health issues and traumatic brain injury to get treatment…”

Given the botched roll-out of the Affordable Care Act’s healthcare.gov website, President Obama should know firsthand that throwing money at a problem is never the solution. Between fiscal year (FY) 2009 and FY 2015, VA funding increased by 68 percent, from $97.7 billion to $163.9 billion. Yet, the number of unique patients in the VHA has only increased by 30 percent, from 4.5 million to 5.9 million. The FY 2015 VA budget request allocated $59.1 billion for veterans’ medical care, $7.2 billion to expand outpatient mental health care, and $3.9 billion for a new consolidated IT program to support modernized information systems.

On May 28, 2014, the VA Office of Inspector General (VAOIG) released an interim report regarding the allegations about the Phoenix HCS. The report substantiated significant delays in access to care that negatively impacted the HCS’ ability to provide quality care to its veterans, possibly resulting in death. Even though the report remains incomplete at this time, the VAOIG identified 1,400 veterans at the Phoenix HCS on the emergency waiting list (EWL), and another 1,700 veterans waiting for primary care appointments that have not been placed on any EWL.

A June 9, 2014 nationwide audit identified more than 57,000 veterans at 731 VA hospitals and outpatient clinics that waited up to three months for medical appointments, while an additional 64,000 veterans have never been seen by a doctor over the past decade. The audit also reported that 13 percent of VA schedulers’ received instructions from supervisors or others to falsify appointment dates in order to meet on-time performance goals.

These reports are not the first to reveal such dismal findings, and unfortunately, they will not be the last. In fact, since 2005, the VAOIG has issued 18 reports that identified, at both the national and local levels, “deficiencies in scheduling resulting in lengthy waiting times and negative impact on patient care.”

Three of those reports, in 2005, 2007, and 2012, examined scheduling procedures, outpatient wait times for service connected veterans, and wait times for veterans included on an EWL. All three reports found that the VHA did not have adequate training programs for schedulers and one report found that 81 percent of surveyed respondents claimed they had received no training on the use of EWLs. The reports also found that managers and supervisors encouraged schedulers to schedule appointments contrary to VHA procedures and policies, resulting in unexplained differences between the desired dates as shown in VistA and those used by the VHA to calculate wait times. These discrepancies led to extended wait times, diminished oversight, and gross mismanagement of critical data.

Despite these well-documented problems, from 2011 to 2013, taxpayers shelled out more than $843,000 in bonus awards to nearly half of the Phoenix Clinic’s 3,170 workers; but that is only one example of such extravagance. Dozens of officials at multiple VA medical facilities under investigation by the VAOIG have received millions in bonuses while the facilities were under scrutiny. On May 23, 2014, a document obtained by Open the Books, a nonprofit group focused on government transparency, revealed that 12,549 bonuses worth $8.8 million were awarded to employees at seven troubled VA hospitals nationwide from 2011 to 2013.

For many years, House Veterans Affairs Committee Chairman Jeff Miller (R-Fla.) has called on the VHA to allow veterans to seek treatment outside the system at private practices, Defense Department facilities, and health facilities run by academic institutions that have federal contracts. On May 21, 2014, Chairman Miller again called on the Obama administration to issue an executive order stating that, “He [Obama] can solve the problem today if he would order his people to allow veterans to seek care – if they can’t get it in a timely fashion in the VA – to seek care in the private system. It appears he's trying to preserve the system as it is. The system is broken.”

On Tuesday, May 27, 2014, two days before his resignation, VA Secretary Shinseki acquiesced to Chairman Miller’s request and, in a brief statement, said the VA would allow more veterans to seek care at private clinics and hospitals in areas where the department’s capacity to expand is limited, in order to meet growing demands for healthcare. The delay in the announcement to finally allow more veterans to seek private care has many wondering why the VA failed to act sooner on the numerous recommendations of the VAOIG and members of Congress.

Secretary Shinseki said that he “underestimated the depth of problems” in the VA system. He removed several senior leaders at the Phoenix HCS and eliminated performance awards for senior VA leaders, making them ineligible for bonus or salary increases in 2014.

In fact, long before the secretary’s private-care announcement, the VA already had the authority, and the funds, to offer non-VA care to veterans to help the department meet patient wait time standards. At the April 9, 2014 House Committee on Veterans Affairs hearing, Assistant Deputy Under Secretary for Health for Operations and Management, Dr. Thomas Lynch, was asked by Chairman Miller if the VHA’s failure to allow veterans to seek private care stemmed from poor leadership. Dr. Lynch stated, “I think that would be a stretch. Our system strives to treat patients within the VHA because we think we do provide good care; we think we provide quality care. I hope that we can identify those circumstances where it may be necessary to send somebody to the private sector thinking we have to use all of the resources that we have.”

The 18 known deaths of veterans at the Phoenix HCS, as well as 23 other acknowledged deaths at VA facilities nationwide caused by delayed care, are a result of treating America’s heroes like second-class citizens. It should not have taken dozens of deaths and nearly a decade of reports to bring the issue to the center of the nation’s political arena.

Although the scandal has forced senior government officials to take some responsibility for the morass of problems with the VA, the department has a long and difficult road ahead. The VA’s mismanagement of both its data and patients does not stem from a lack of funds, but systematic issues that can only be fixed from the inside out. Until scheduling procedures and policies are reconstructed and followed precisely, and management tools are utilized to appropriately target flaws, the VA’s integrity and efficiency will continue to be questioned.

Our veterans defended the freedom of a country they love and respect and deserve nothing less than the absolute truth and the best possible care.